Healthcare Provider Details

I. General information

NPI: 1912979634
Provider Name (Legal Business Name): BRIAN BERNARD LUPFER PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 3RD ST W 12 MEDICAL GROUP BLDG 1040
RANDOLPH AFB TX
78150-4800
US

IV. Provider business mailing address

221 3RD ST W 12 MEDICAL GROUP BLDG 1040
RANDOLPH AFB TX
78150-4800
US

V. Phone/Fax

Practice location:
  • Phone: 210-652-2117
  • Fax: 210-652-7128
Mailing address:
  • Phone: 210-652-2117
  • Fax: 210-652-7128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: